Exploring the pedagogical design features of the flipped classroom in undergraduate nursing education: a systematic review

Globally, nursing educational institutions are taking steps forward in redesigning their curricula to align them with modern pedagogy to enhance student-centred learning [1]. This curricular reform is concerned with fulfilling the educational needs of the new technological era, which generates exposure to a variety of information, advanced communication technology, and diverse learning methods [2]. As a result, blended learning has become part of this curricular reform. Blended learning is a broad pedagogical approach, which encompasses a combination of face-to-face and online teaching to promote student-centred learning [3]. One of the blended learning innovations is the notion of the flipped classroom [4], referred to as “a hybrid approach to learning, using technology to move the classroom lecture to homework status and using face-to-face classroom time for interactive learning” [5]. The rule of thumb of the flipped classroom is redesigning the face-to-face classroom as an interactive learning environment where higher-ordered learning takes place, while providing traditional pedagogical experiences (of transferring basic information) through pre-class learning activities [4, 6‐8]. As such, pre-class learning materials can be provided to closely represent learning in the traditional face-to-face classroom but being delivered electronically or via online media [9]. Therefore, pre-learning materials should be accompanied with teachers’ explanation rather than relying on the sole use of pre-class reading materials [6].

Contemporary nursing care is advancing dramatically due to the need for nursing students to manage problems associated with multiple and complex clinical comorbidities [10]. It was reported in the literature that nursing students experience difficulties in applying learnt knowledge in clinical practice [11]. This necessitated the need for nursing curricular implementers to adopt pedagogies like the flipped classroom to ensure that theoretical concepts were explicitly linked to patient care. As such, the flipped classroom is considered as a new educational paradigm for implementing health professions’ education curricula [6, 12]. While there are increasing applications of the flipped classroom, there is a dearth of evidence evaluating its impact on student learning and curriculum design in undergraduate nursing education [13‐15]. The empirical evidence to date has predominantly examined the effectiveness of the flipped classroom through students’ satisfaction and academic performance [13]; however, there is limited evidence to explain the pedagogical design principles of the flipped classroom, which are indispensable to achieving meaningful educational effectiveness [16]. Thus, the following systematic review aims to describe and evaluate research conducted in the area of designing, developing and implementing the flipped classroom, and appraise the educational impact of the flipped classroom approach when applied to undergraduate nursing education.

This systematic review was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocols (Additional File) [17]. PRISMA is an evidence-based system used to guide reporting in systematic reviews and meta-analyses [18]. The protocol was registered with the PROSPERO (International prospective register of systematic reviews) (CRD42020194474, 16th October 2020).

This systematic review explored and evaluated the flipped classroom in the context of undergraduate nursing education. In particular, the systematic review addressed two main aspects – one focusing on the design and development of flipped classroom pedagogy in undergraduate nursing education and the other evaluating the impact of the flipped classroom on undergraduate nursing students’ learning.

The systematic review identified 27 studies that investigated the flipped classroom experience among undergraduate nursing students. According to the evidence hierarchy classification model [21, 22], most of the selected studies reached the evidence category of IIb or above and all of them achieved operational rank “A”, indicating a catchment of high quality papers. A variety of methodologies, including educational measures were used to determine the impact of the flipped classroom on undergraduate nursing students’ learning. As the studies varied significantly, it is not easy to perform a direct comparison between studies due to the degree of heterogeneity. Nevertheless, the results of the selected studies revealed that a common operational pedagogical structure (Fig. 4) was generally utilised regardless of instructional system designing principles (except for two studies) and the flipped classroom resulted in positive learning outcomes among undergraduate nursing students.

Taking the flipped classroom design into consideration, studies investigated the flipped classroom design in reference to both micro and macro levels [24, 45]. The micro level concerns developing flipped classroom pedagogy for a session or topics [45, 46]. In contrast, the macro level involves instructional system design at the curriculum or course level [45, 47]. Most of the selected studies included in this review examined the flipped classroom at the micro level. Interestingly, the three-step flipped classroom operational model (Fig. 4) describes the flipped classroom design at the micro-level. It was noted that the common operational model was utilised in different forms. For example, Oh et al. (2019) used the basic operational model in eight steps which is called the “C-REVERSE” design with the use of film clips [24] and “flipped-mastery classroom model” was used in the South Korean clinical nursing practicum curriculum [25]. However, the existing findings emphasize that the benefits of the flipped classroom did not eventuate based on sticking purely to the common operational model, but rather caused by the logical connections between the different steps [45, 48, 49].

Some studies included the pre-classroom activities and post-classroom activities under a common cluster of online-learning phase and in-classroom activities labelled as face-to-face learning phase [1, 39, 43, 45, 50]. Three important concerns were reported for developing the online learning phase [45, 46, 51] through evaluating the: (i) physical feature of the video or online lectures which includes duration, pacing and quality of audio; (ii) content feature of the video or online lecture such as appropriate provision of the online portion, clarity and interactivity; and (iii) logistic feature of the video or online lecture namely formative assessment, timetabling and follow-up activities. Designing the face-to-face learning phase is crucial because it is the core part of the flipped classroom [45]. The current review suggests four cardinal activities of the in-class activities, namely dividing students into small groups, conducting a diagnostic assessment, micro-teaching, and continuing integrative student-centred instructions. Furthermore, it has been suggested that the face-to-face learning phase should include: (i) introductory tasks such as mini-lecture and authenticating quizzes; (ii) interactive learning activities which are aligned with the intended learning outcomes; and (iii) well established ground rules and learning culture [45, 46, 52, 53].

In terms of macro-level design, the review identified that the ADDIE model created a framework for designing the flipped classroom for undergraduate nursing students [24]. The ADDIE model has been recognized as effective, systematic and efficient in designing the flipped classroom in nursing education [54, 55]. Moreover, the ADDIE model has achieved acceptance in diverse fields [56, 57]. The ADDIE model proposes five straightforward steps when developing the pedagogical strategies used ensure curriculum planners and implementers reach the ‘appropriate destination’ [56]. In addition, the review traced the design principles of the flipped classroom. Lee and Park (2018) adopted nine design principles (Fig. 3) for developing flipped classrooms in reference to the surgical nursing practicum [15]. Kim et al., (2014) proposed the flipped classroom design principles for enforcing student-centred learning through four key variables, namely cognitive presence, social presence, teaching presence, and learner presence [58].

In reviewing the impact of the flipped classroom on undergraduate nursing students’ learning, positive outcomes were reported in many studies included in this review. More specifically, nursing students’ knowledge, skills and attitudes were improved by the flipped classroom learning, in terms of assessment performance, performing core skills, problem-solving, communication, critical thinking, self-directedness, motivation, engagement, confidence, satisfaction, and joyful learning. Besides, the notions of positive outcomes were reported among students from other discipline such as dentistry, medicine, pharmacy [59‐63]. It was reported from the literature that two main explanations contributed to the positive learning outcomes. Firstly, unimpeded access to the pre-classroom learning materials enabled nursing students to learn in their preferred place, pace and time. Specifically, the pre-recorded video lecture was used as the main pre-classroom learning material. The nursing students who watched the video lectures developed a better understanding of learning concepts [6]. Secondly, in-classroom activities were designed as an interactive and student-centred environment which provided greater opportunity to apply the learned concepts into practice [1]. On the other hand, some studies still favoured the traditional lecture-based learning [30, 41]. This may be due to the preference for behaviouristic learning in higher education. Overall, the findings so far seem to suggest that we still have mixed results on whether flipped classroom increases test scores; however, there seems to be strong evidence to suggest that flipped classroom can increase student motivation, satisfactory, and critical thinking.

These findings present two important implications for developing and implementing the flipped classroom in undergraduate nursing education. Firstly, contextual compatibility is more important for the success and sustainability of a pedagogical model. Thus, it is essential to follow an instructional system design at the macro-level to develop flipped pedagogy rather than using its’ operational structures alone at the micro-level. The review identified the ADDIE model and the three-step operational model (Fig. 4) for fostering flipped classroom at the macro and micro level, respectively. Secondly, it was noted that the flipped classroom resulted in positive learning outcomes among nursing students. This outcome may be optimised by balancing the workload of pre-, in-, and post-class activities at the micro level, rather than providing more emphasis on one phase. Furthermore, a study reported that the flipped classroom was not welcome by stakeholders during the introduction phase [36]. Consequently, the solidity of the flipped classroom intervention relies on the constant and stable plan of implementation.

This review could have limitations derived from the heterogeneity of study designs. Apart from meta-analysis, randomised controlled studies, and quasi-experimental studies, we also included several non-experimental descriptive studies to cover the range of available evidence. This heterogenous sample of studies does not permit further probing of the evidence, such a meta-analysis of the study outcomes; however, our sample represents the commonly-used and ethical research methods in educational research and provides a starting point for generating higher levels of evidence. Moreover, the reported findings are mainly from the United States of America and South Korea, which are likely well-resourced settings. Consequently, there may be cultural and regional bias in these studies like ethnocentrism, available resources and educational system. Thus, future research could be conducted in other settings, including low and middle-income countries, to strengthen the evidence base.

The evidence cited in this systematic review suggests that incorporating the flipped classroom pedagogy probably yields promising positive educational outcomes in undergraduate nursing education. The majority of the studies utilized a common operational flipped classroom structure as pre-classroom, in-classroom and post-classroom. Furthermore, there are promising instructional system design models available for adapting or developing a flipped classroom. Practical implications of the review are considering contextual compatibility and providing equal importance to all three phases of flipped classroom for augmenting the educational outcomes. In addition, the feasibilities of developing the flipped classroom in a limited-resourced setting are still inconclusive. Therefore, future research should consider developing and implementing flipped classrooms for the limited-resourced undergraduate nursing educational environment by using a compatible instructional system designing model.